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Reality Check 2

New one for me - primary biliary cirrhosis and esophageal varices in a DOT driver

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I am looking ahead on my schedule to see what awaits Monday.

 

Have a DOT exam on a 53 yr male who sees my partner and a GI doc.

 

Listed as primary biliary cirrhosis with NO alcohol involvement and esophageal varices.

 

Have not met this patient yet but have concerns and am researching.

 

BMI 32, normo if not low tensive but not hypo, nonsmoker.

 

GI lists Child Class A and MELD 9 - researched that since not in my daily vocab - very lowest on scales of mortality with 2 yr survival at 85%

 

The esophageal varices worry me the most. He has 2+/ 2 channel varices on nadolol to reduce risk of bleeding.

 

My first DOT impaired behind the wheel thought  --- sudden coughing fit and varices rupture and he bleeds out and wrecks the truck into a school bus full of kids.

 

Turns out he works for the railroad but goes out on the tracks in company vehicles and big equipment. 

 

GI says "don't lift heavy things"..... ummm, helpful - not. What does that mean - 20 lbs?.... I know it increases intrathoracic pressure with lifting and risks the varices. What is the actual risk? 

 

Natalie Hartenbaum's book doesn't address this particular issue.

 

Looking for some GI colleagues or DOT junkies to throw out some advice.

 

I will undoubtedly be calling the GI doc who will have zero understanding of DOT........................

 

Trying to work ahead and avert issues.......................

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I'd say no just based on the esophageal varices, BUT allow a GI doc to say that there's insufficient risk of rupture and he's OK to operate heavy machinery, and only issue a 1 year medical examiner's cert on that basis IF you believe the GI doc... because you're allowed to approve based on specialists' input, but it is ultimately your call.

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first thought that comes to mind is Sengstaken–Blakemore tube, lots of fun with high potential for litigation, second thought projectile hematemesis, i would not like the driver next to me to have either,

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I don't want to "end" some guys career but he is sick and has a lot of unknowns.

 

I too wonder if his varices will rupture while he is out on the railroad track and he and his truck will be hit by a train when he is disabled and can't get out of the way.

 

Monday I will get to talk to the GI doc - IF I can get him on the phone....... 

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Guest UVAPAC

I'd say no just based on the esophageal varices, BUT allow a GI doc to say that there's insufficient risk of rupture and he's OK to operate heavy machinery, and only issue a 1 year medical examiner's cert on that basis IF you believe the GI doc... because you're allowed to approve based on specialists' input, but it is ultimately your call.

 

It is ultimately "our call" however I like to defer to specialists, especially in difficult decisions.  Obviously we are not board certified cardiologists, gastroenterologists, surgeons, etc, and it is made clear that clearance letters and input should be obtained from specialists.  When there are recommendations from FMCSA or Nathalie Hartenbaum's book, I will copy and paste them directly into our office letterhead, and send it to the specialist for their input.

 

Obviously I would never certify anyone I felt it was unreasonable, however there are cases that I am simply unclear on, and will defer to a specialist.

 

I recently had a patient with "moderate to severe aortic insufficiency" coupled with a history of atrial fibrillation on an anti-arrythmic medication.  I copied and pasted the guidelines for "severe aortic insufficiency" which had 4 particular standards which must be met in order to certify.  The board certified cardiologist commented on each of the four, stating his patient met these requirements, and that issuing a 6 month card was appropriate.

 

Subsequently I issued him a 6 month card.  If there was ever an accident (which hopefully there will never be) I have an "expert" on record stating that the patient meets each of these requirements.  Who am I to question his authority, especially when he is aware of the recommended guidelines/standards.

 

 

In this case it is slightly more difficult as there is not much literature available with esophageal varicies and DOT PE.  I do believe this is a case in which a specialist (GI) should be consulted.  They should be made aware he is a train conductor (or whatever he is) and will have lives in his hands.  I would mention part of a DOT PE is ensuring that these drivers can load/unload trucks and carry heavy equipment with no restrictions or limitations.  If they feel he can't lift 10-15 pounds, the answer is no.  If he can lift up to 50 pounds, I would consider.  

 

I strongly feel that there is no one who can be an expert in all fields of medicine, and therefore we must consult with each other to improve patient outcomes and make the best decisions possible... 

 

I have gotten letters from specialists stating a patient is safe to drive (on 160 morphine equivalents daily) and have denied them.  This is a case where I would defer to GI.  

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      I'm just curious.... I am taking an NRCME online course right now for DOT. I start my new position in Occ Med and UC soon.
       
      How long did you study the NRCME materials after taking the course before you took the exam?
       
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